www.wageworks.com
3833-STD (12/2016)
Claim Filing Options:
• Toll-free fax: (877) 353-9236.
• Or, Mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512
ACCOUNT HOLDER INFORMATION
Last Name First Name
ID Code (last 4 digits)* Employer / Program Sponsor’s Name
Zip Code Birth Date (MM/DD) Email address (complete only if new)
INSTRUCTIONS
1. Complete this form in its entirety.
2. Include proof from your High Deductible Health Plan (HDHP) provider that verifies you and/or your covered family member(s) met
the IRS required minimum annual deductible with in-network expenses for your plan and the service date for which it was met.
For example, an Explanation of Benefits (EOB).
3. Submit (1) this completed form and (2) documentation of proof of when you met the IRS required minimum annual deductible to
the fax number that appears at the top of this page.
4. Please send/fax your HSA claim under a separate submission after this HDHP form has been submitted to ensure appropriate
claims handling.
HDHP DEDUCTIBLE INFO
Per IRS Regulations, you must submit proof of having met the statutory minimum annual in-network deductible in order to switch from
HSA-Compatible (Limited) to Standard coverage. Your HDHP documentation will need to indicate you met the statutory minimum annual
deductible indicated below.
Select ONE to indicate your level of coverage, deductible amount met, and for which calendar year:
LEVEL OF COVERAGE MET 2016 DEDUCTIBLE MET 2017 DEDUCTIBLE
Single $1,300 or more $1,300 or more
Family (one or more) $2,600 or more $2,600 or more
Your deductible may be higher but cannot be lower than the annual statutory limits displayed above.
Enter the Date of Service for the medical care that enabled you to meet your in-network statutory minimum annual deductible:
Date Statutory Minimum
Annual Deductible Met
Date of Service on attached HDHP documentation
MM DD YY
CERTIFICATION AND AUTHORIZATION
Submission of this form and the accompanying documentation from your High Deductible Health Plan (HDHP) provider serves as certification
that you have met the statutory minimum annual deductible and that your Health FSA will now accept all eligible 213(d) medical expenses—
enabling the payment of any eligible medical, pharmacy and/or over-the-counter expenses covered by your plan—as of the date you met
your statutory minimum annual deductible. You will need to elect HSA-Compatible coverage during open enrollment in order to continue
to qualify for an HSA during the following year. Use of this service indicates your acceptance of the WageWorks User Agreement (available
upon registration at www.wageworks.com; enter user name and password or click on the Employee Registration link).
By submitting this form and the accompanying documentation you are certifying this is true and correct under the penalty of perjury.
* Your ID Code is the last 4 digits of your Social Security Number, your Employee Number or other reference number assigned by your program sponsor. Please check the
enrollment instructions provided by your program sponsor for more information about your ID Code
HSA/HDHP DEDUCTIBLE FORM
Proof of Having Met Annual HDHP Deductible
